249 Lot5 Application for Disposal System 2015 Commonwealth of Massachusetts
TSI=` - City/Town of Florence
Number
5
Application for Disposal System oe
Construction Permit Fee
Form 1A ?� U
ci..eck
DEP has provided this form for use by local Boards of Health if they choose to do so. Before using
the form, check with your local Board of Health to make sure that they will accept it.
A. Facility Information
Important:
When filling out Application is hereby made for a permit to: ® Construct a new on-site sewage disposal system
forms on the ❑ Repair or replace an existing on-site sewage disposal system
computer, use ❑ Repair or replace an existing system component
only the tab key
to move your
cursor-do not 1. Location of Facility:
use the return
key. Lot#5- Sylvester Road- Formerly Lot of Mark Lavalley
Address or Lot#
Florence MA. 01060
City/Town State Zip Code
MID;' X
2. Owner Information
Davio and Hathaway Development
Name
Address(if different from above)
Southampton MA 01073
City/Town State Zip.Code
(413) 478-0268-Mark Davio
Telephone Number
3. Installer Information
Mark Lavalley
Name Name of Company
Sylvester Road
Address
Florence MA 01062
City/Town State Zip Code
(413)586-3779
Telep' Of
TIMOTHY \<(?:\
4. Designer Information [1 E. ti
�it 1.1 tr1AQ1N1itS
Timothy E. Maginnis R.S., LSE luAx� �i , : • .�
Name ;- • . �.�, •
70 Montague Road
Address ��
Westhampton MA. 01027
City/Town State Zip Code
(413) 527-5291
Telephone Number
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
Cit /Town of Florence Nud 1
Application for Disposal System
$ 5'D
Construction Permit Fee
Form 1A
A. Facility Information (continued)
5. Type of Building:
® Dwelling ❑ Garbage Grinder(check if present)
Other: Type of Building 8
Number of Persons Served
❑ Showers Number of showers El Cafeteria 1:1 Other fixtures
Specify other fixtures:
440 gpd
6. Design Flow: Gallons per Day
Calculated Daily Flow: 440 gpd
Gallons
7. Plan: June 23, 2015
Date of Original
2
Number of Sheets Revision Date
Plan of Subsurface sewage disposal system
Title of Plan
8. Description of Soil:
Sandy loam -gravelly sand
9. Nature of Repairs or Alterations (if applicable):
N/A-This is new construction
10. Date last inspected: N/A
Date
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
="-4= Cit /Town of Florence a0/6"
Number
Application for Disposal Systemstem $ /(1- 1 °611_ s
w
Construction Permit
Fee
Form 1A
B. Agreement
The undersigned agrees to ensure th- onstruction and maintenance of the aforedescribed on-site
sewage disposal system in accr r= .e provisions of Title 5 of the Environmental Code and
not to place the system in o. .0 '" =s-• • cate of Compliance has been issued b this Board
of Health.co' '- (2 * y
i t.
Sgnatu -• - MAB>lllr}t8 I i Date
082
Application Approved By: �,� t
ii s�+. �►. 6/.30/g
Date
Appli t. i p o he following reasons:
DDG 1 IF"Iii
Conditions:
N.- 'IAMPTON BOARD1).System Designer must inspect and verify in writing
2 jAA�>H�jRE OF HEALTH That the sewage disposal system was installed
Ai In accordance with the approved plans ani Title S.
QM-HAMPTON
, MA 01060 2).If this is a system with the S.A.S.constructed in
Title 5 fill the System Designer must conduct a bottom
inspection of the excavated area prior to the placement
of the fill
3).No changes can he made&rri:,,.rn•.etn•rtion by the
Installer without prior.y ,!,.•,,,, ,
Designer and the Board ul tleatth 1' i,,t.
4).Other conditions:
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